COMPARISON BETWEEN PRF AND GELATIN SPONGE AS FILLING

*Corresponding Author Address: Dr. Majd Albounai. E-mail: [email protected]

International Journal of Dental and Health Sciences

Volume 04,Issue 06

Original Article

COMPARISON BETWEEN PRF AND GELATIN

SPONGE AS FILLING MATERIALS IN LATERAL

SINUS LIFT PROCEDURES CONCURRENTLY WITH

IMPLANT PLACEMENT Ali Khalil1, Majd Albounai2 1.Ass.Prof. ,Department of oral and maxillofacial surgery, Faculty of Dentistry,Tishreen University 2.MSc student Department of oral and maxillofacial surgery, Faculty of Dentistry,Tishreen University

ABSTRACT:

Aim of study: was to compare the effectiveness of PRF (platelet rich fibrin) with gelatin sponge as filling materials in lateral sinus lift procedures simultaneously with implant placement. Materials and Methods: This study included 20 patients underwent unilateral sinus floor lifting with simultaneous placement of 24 implants. In 10 patients we used the PRF as a sole filling material in the sinus and in other 10 patients we used the gelatin sponge. For each patient presurgical and 3 postsurgical (8days,3and6 months) panoramic x-rays were performed. Results: The residual bone height was 3.9-6.8mm in PRF group, and 4.1-6.9mm in gelatin sponge group. After 3 months there was statistically significance difference in bone gain between the two groups and higher in PRF group (5.53±1.10mm in PRF and 3.07±1.54mm in gelatin sponge) .But there was no statistically significance difference in total bone gain after 6 months between the two groups (6.55±1.36mm) and (6.05±1.13mm) respectively. All implants in tow groups were clinically stable after 6 months. Conclusion: both of materials could considered appropriate for this kind of procedures when implants are inserted in the same stage. However we think that PRF is better since the bone formation was faster in PRF group. Key words: lateral sinus lift, autologous platelet rich fibrin, gelatin sponge, implant

INTRODUCTION:

The atrophic posterior maxilla is a

challenging site for oral rehabilitation

with dental implants due to insufficient

bone volume to accommodate dental

implants. Crestal approaches or lateral

window approaches for sinus

augmentation are the most common

surgical techniques to overcome vertical

deficiencies of the atrophic posterior

maxilla.[1-4] Using these approaches,

implant placement can be performed in

one or two surgical stages depending on

the residual alveolar bone height. A

minimum of 4 to 5mm was

recommended for a one-stage surgical

procedure (simultaneous implant

placement). Implant stability in the

residual bone height is a key issue.[5-7]

Recently, a new approach was

developed based on the concept of

guided bone regeneration.[8] Several

authors showed that a full sinus lift can

be performed using the lateral approach

with whole blood as the sole filling

material.[9,10] This strategy requires the

Khalil A.et al, Int J Dent Health Sci 2017; 4(6):1316-1328

1317

implants to be stabilized in the residual

bone height and to maintain the

Schneiderian membrane pushed in the

highest possible position using implant

tips as tent pegs. Filling the sinus cavity

with a stabilized blood clot remains quite

difficult to control. The use of blood

preparations such as platelet rich fibrin

or material serve as a matrix for blood

clot formation such gelatin sponge seem

an interesting options to improve this

sinus-lift approach.[11]

Choukroun’s platelet-rich fibrin (PRF)

was first described by Choukroun et

al.[12] in France in 2001. The protocol is

very simple, and many PRF clots can be

produced in <20 minutes.[13,14] The use of

PRF during sinus- lift procedures has

been advocated for many years during

lateral sinus-lift.[15,16,17]

Due to its hemostatic properties, gelatin

sponge has been widely used in surgery

as a wound dressing, adhesive and

absorbent pad.[18] The advantage of

gelatin over collagen matrix is its ease of

extraction and preparation, which

results in a cheaper and high quantity

production of gelatin matrix.

Furthermore, unlike collagen, gelatin

does not express any antigenicity in

physiological conditions.[19] Due to

flexibility in shape, biocompatibility,

affinity to proteins, and biodegradability,

gelatin-derived sponges may be

excellent candidates for bone graft

scaffolds in low-load areas or as drug

delivery materials. Gelatin sponges were

successfully implanted in the defective

areas of jaw after cyst enucleation.[20]

Also successful new bone formation in

cases of sinus membrane elevation with

using absorbable gelatin sponge as a sole

filling material with immediate implant

placement was reported.[21]

The objectives were to assess the

relevance of both PRF clots and Gelatin

sponge as filling materials during a

lateral sinus lift procedures with

immediate implantation using radiologic

analyses in a case series and determine

which material is more effective in such

procedures.

MATERIALS AND METHODS:

Patient Selection and Study Design

This case series consists of 20 unilateral

sinus elevations performed on 20

patients between July 2016 and July

2017 at the Department of Oral and

Maxillofacial Surgery, Tishreen

University, Lattakia, Syrian Arab

Republic.

The patients were randomly divided into

two groups. PRF group: consisted of 10

patients in which we used the

autologous platelet rich fibrin (PRF) as a

sole filling material after sinus

membrane elevation, and gelatin sponge

group: consisted of 10 patients in which

we used the gelatin sponge as a sole

filling material after sinus membrane

elevation.

The patients were informed about the

aim and design of the study, and written

consent was obtained.


1318

Patients with contraindicating systemic

conditions were excluded. The inclusion

criteria included absence of acute

maxillary sinus inflammation no or a

minor smoking habit (less than five

cigarettes per day). The clinical

examination and preoperative

radiographs showed atrophy of the

maxilla in the premolar/molar area that

required a sinus lift before implantation.

All of the cases in this preliminary series

needed relatively small sinus lifts, with

only one or two implants required per

sinus. For each patient, a presurgical

radiologic exam was performed using

panoramic x-ray to evaluate the

subsinus residual bone height (Fig. 1).

The patients included 10 males (50%)

and 10 females (50%) with a mean age of

(38.4 ± 5.2) years (range: 23 to 67 years).

Presurgical standard blood analyses

showed normal blood variables,

particularly platelet and leukocyte

concentrations.

The mean subsinus residual bone height

was (5.40 ± 0.97 mm) in PRF group and

(5.46 ± 0.90 mm) in gelatin sponge group

.The width of the alveolar bone ridges

was considered a noninterfering

parameter because the width was always

sufficient for a secure implantation.

PRF Preparation

PRF clots were prepared as described by

Choukroun et al.[12] During surgery, 50 ml

whole blood was drawn into five glass-

coated plastic tubes without

anticoagulant and was immediately

centrifuged at 3000 r\min for 12 minutes

using preparation kits and a centrifuge

specifically designed for this application.

The coagulation cascade lead to the

formation of a natural fibrin clot in the

middle of each tube. Clots were stored in

metal cups before sinus filling.

Surgical Technique and Postoperative

Management

Surgery was performed with local

anesthesia. Access to the buccal

maxillary wall was achieved via a

mucosal crestal incision, anterior and

posterior releasing vestibular incisions,

and full thickness flap elevation (Fig. 2A).

A bone window was outlined using

rounded surgical bur with constant saline

irrigation (Fig.2B). After careful elevation

of the Schneiderian membrane , the

bone window was left attached to the

membrane and served as a new sinus

floor (Fig. 2C). The size of the window

was always kept as small as possible to

protect the osteogenic potential of the

sinus cavity.

Implant sites were prepared with careful

undersized drilling.

The implant is inserted in compression

within the residual alveolar bone. The

end of the implants always touched the

elevated sinus membrane, and served as

tent pegs (Fig.2 D and E).

In PRF group: Five PRF clots were

inserted in compression inside the sinus

cavity to fill all of the volume stabilized

with the implants (Fig. 2F).


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In gelatin sponge group: 5 pieces of

gelatin sponge were inserted inside the

sinus cavity to fill all the volume

stabilized with the implants.

For postoperative management,

medications were prescribed, including

chlorhexidine rinses twice a day for 14

days, 1 g amoxicillin two times daily for 6

days (clindamycin, 500 mg · 2, two times

daily, was used for penicillin-sensitive

patients), ibuprofen (600 mg) three

times daily unless medically

contraindicated, and pain medication as

needed for pain. Patients were not

allowed to use any removable

prosthesis. The sutures were removed 8

to 10 days postoperatively, and a

panoramic x-ray was taken to check the

position of the implants (Fig3).

Radiographic Follow-Up

For each patient, a panoramic x-ray was

obtained 8-10 days after the procedure

and after 3 and 6 months to evaluate the

bone gain around each implant in the

sinus (Fig. 3, 4 and 5) and validate the

next step of the treatment. After surgical

uncovering, all implants had healing

screws placed at 25 Ncm. At a later date,

impressions were taken, and implant

supported metal-ceramic crowns were

placed within 2 to 4 weeks thereafter.

The aim of the radiographic analysis was

to determine, the bone gain around each

implant 3 months after sinus-lift surgery

and after 6 months. Thus, each

Panorama radiograph was analyzed

using the Digora software. Tow

measurements of the residual bone

levels were performed around each

implant (1 mm mesial, 1 mm distal) after

8 to 10 days and after 3 months and 6

months. For each implant, the mean

bone gain was calculated in every stage.

Also the density of the bone which newly

formed in the sinus was measured

around each implant after 3 months and

6 months using Digora software.

The data were analyzed statistically using

SPSS software. We used t's student test

to compare PRF group with gelatin

sponge group.

RESULTS:

This case series included 20 unilateral

sinus elevations performed on 20

patients who fulfilled the inclusion

criteria and were treated with 24

implants. After surgery, healing was

uneventful for all patients. Six months

after surgery, all implants were clinically

stable during abutment tightening.

The residual bone height range between

3.9 and 6.8 mm (mean ± SD: 5.40 ± 0.97

mm) in PRF group and between 4.1 and

6.9mm (mean ± SD: 5.46 ± 0.90 mm) in

gelatin sponge group and there was no

statistically significance difference

between the two groups regarding the

residual bone height. Early postoperative

panoramic radiographs (8 to 10 days

after surgery) showed implants inserted

in the sinus cavity without dense tissue

around them, since PRF and gelatin

sponge fillings being radio transparent.


1320

After 3 months the mean bone gain was

5.53 ± 1.10mm in PRF group and 3.07±

1.54mm in gelatin sponge group. P value

was 0.001 (˂0.01) which means that

there was statistically significance

difference between the two groups

regarding bone gain after 3 months and

higher in PRF group.

Between 3 and 6 months the main bone

gain was 1.03 ± 0.80mm in PRF group

and 2.98 ± 1.12mm in gelatin sponge

group. P value was 0.000 (˂0.01) ) which

means that there was statistically

significance difference between the two

groups regarding bone gain in the time

between 3 and 6 months after surgery,

but this time higher in gelatin sponge

group.

The mean of total bone gain was 6.55 ±

1.36mm in PRF group and 6.05 ± 1.13

mm in gelatin sponge group. P value was

0.375 (˃0.01) although the mean of total

bone gain after 6 months was higher in

PRF group there was no statistically

significance difference between the two

groups. (table1)

After 3 months and using Digora

software the density of newly formed

bone in the sinus was 130.37 ± 5.52 mm

in PRF group and 118.85 ± 4.61 mm in

gelatin sponge group. P value was 0.000

(˂0.01) which means that there was


between the two groups

After 6 months the density according to

Digora software was 147.82 ± 5.83 mm

in PRF group and 135.54 ± 4.14 mm in

gelatin sponge group. P value was 0.000

(˂0.01) which means that there was


between the two groups. (table 2)

In all cases no implant was lost, leading

to a 100% success rate after 6 months in

tow groups.

DISCUSSION:

Sinus lift without bone graft material

Bone graft material was considered a

prerequisite for the clinical success of

dental implants inserted into the

augmented maxillary sinus. Ginnady

Pinchasov in 2014 found in his literature

review clear radiological evidences to

bone formation in the sinus after using

lateral window technique for the lift

while using blood clot alone for the bone

formation.[22] The osteoinductive

properties of the blood clot alone have

been stressed in various studies.[23]

In our current clinical study, it was found

that new bone can form directly on and

around inserted dental implants without

the use of bony substitutes and using

only either the autologous PRF or the

gelatin sponge as filling material in the

lifted sinus. Thus, the cost-effectiveness

and time-saving benefits are obvious, as

instead of using autogenous bone or

allografts, which involve a remodeling

period of 6 months or 9-12 months,

respectively, implants can be placed at

the time of sinus lifting and left to

osseointegrate without bone

substitutes.{24,25]


1321

Many studies suggested that the key role

to this bone formation lies in

Schneiderian membrane and the bone

gain does not depend much on the type

of grafting material used.[26] The leading

reason to the bone regeneration is the

innate osteogenic potential of the

Schneiderian membrane and the basic

principle behind bone formation is by

guided tissue regeneration. While not all

of the factors for this verity are clear, as

well as the exact bone formation

mechanism, it is possible that efficient

space-maintaining management predicts

an increase in bone gaining.[27,28]

The use of PRF and gelatin sponge in

lateral sinus floor lift procedures

In the first international publication on

using the PRF in sinus lift, it was assessed

that a sinus grafting material built with

an allograft and PRF in equal volume was

suitable for implantation after only 4

months and potentially even more

mature than a sole allograft after 8

months.[29] Another study showed that

PRF membranes were easy to use during

a Summers osteotomy and offered a

good compromise as a filling material

and shock absorber during sinus floor

elevation and provided healing support

for the damaged Schneiderian

membrane.[30]

Ziv Mazor et al declared in his case series

that the use of PRF as the sole filling

material during a simultaneous sinus lift

and implantation stabilized a high

volume of natural regenerated bone in

the subsinus cavity up to the tip of the

implants.[31].

The results of our study agreed with

results of Ziv Mazor's study that PRF is a

valid filling material in lateral sinus floor

procedures, since the bone formation

was clear in all cases in PRF group.

Alain Simonpieri et al 2011 performed

Twenty-three lateral sinus elevations on

20 patients with simultaneous implant

placement and used the L-PRF as sole

filling material under the sinus

membrane, The maximum follow-up was

6 years, and all patients were followed

up for a minimum of 2 years. No implant

was lost during this 6-year experience,

and the vertical bone gain was always

substantia.[32]

The results of our study agreed with the

results of Alain Simonpieri 's study, since

the bone formation was sufficient in PRF

group and all implants were stable

during abutment tightening.

Sohn et al performed 9 sinus membrane

elevation with using absorbable gelatin

as a sole filling material with immediate

implant placement in 7 patients and 18

implants were inserted. After uncovering

the implants an average of 6 months

after placement, new bone consolidation

in the maxillary sinus was observed on

radiographs without bone graft. Two

implants were removed due to failed

osseointegration on uncovering. Failures

were caused by insufficient initial

stability.[21]


1322

In our study bone gain was clear in all

cases of Gelatin sponge group and all

implants were stable after 6 months of

healing period, initial stability was crucial

in our study.

While the success with this technique is

similar to those of conventional

procedures, there is less contamination

associated with this procedure, as no

external grafts and/or additional

surgeries are involved. With this line of

reasoning, a broad and firm consensus

has been established regarding the

importance of blood clot formation,

which serves as autogenous graft filler

material for bone regeneration during

graftless maxillary sinus lifting.[22,23]

PRF or Gelatin sponge?

In this study we compared the

effectiveness of the natural blood clot

which formed in gelatin sponge group

with the autologous PRF which

considered as optimized blood clot when

they used as filling materials in lateral

sinus lift simultaneously with implant

placement.

We found that new bone formation in

the sinus was evident in both groups.

After 6 months the main of total bone

gain was higher in PRF group comparing

with gelatin sponge group [(6.55 ± 1.36

mm) and (6.05 ± 1.13 mm) respectively]

but there was no statistically significance

difference, both of these materials

served as scaffold for formation of blood

clot which finally replaced by new bone,

we can conclude that the key factors of

success of sinus lift are the space

maintenance which achieved in our

study by placement the implants in the

same stage and stabilized blood clot

which was achieved in our study either

by using the gelatin sponge or by using

the autologous PRF.

After 3 months the main of bone gain in

PRF group was statistically higher than

gelatin sponge group (5.53 ± 1.10mm

and 3.07 ± 1.54mm) respectively. It could

be because the properties of PRF which

considered as an optimized blood clot.

Many research suggested that PRF may

improve the healing of Schneiderian

membrane and stimulate its periosteum

like behavior and perhaps increase or

stabilize the bone volume around the

implant end.[33,34] Moreover PRF releases

growth factors, such as transforming

growth factor, vascular endothelial

growth factor, and platelet-derived

growth factor.[35] These major growth

factors released from platelets stimulate

cell proliferation and migration to

promote wound healing.[36], and maybe

that's why bone gain was higher after 3

months in PRF group comparing with

gelatin sponge group. The density of

newly formed bone was significantly

higher in PRF group comparing with

gelatin sponge group after 3 and 6

months that’s could be because the PRF

has strong matrix architecture which

calcified faster and more effectively than

natural blood clot.

CONCLUSION:

We can conclude that both of autologous

platelet rich fibrin and gelatin sponge are


1323

suitable as filling materials in lateral

sinus floor lifting when there is sufficient

residual alveolar bone height to insert

the implants in the same procedure.

However we found that PRF is more

efficient since the healing was more

rapid, so we could decrease the healing

period for 4 months. And we

recommend more researches about this

issue.

- Having narrow smile fullness

(28%buccal corridor) should be included

in the problems list.

- Excessive teeth showing with 2% buccal

corridors showed to be not the most

attractive smile in this study.

- Medium broad smile fullness

(10%buccal corridor) considered to be

the most attractive.

- There was no significant difference in

judging the effects of buccal corridors on

the smile attractiveness between male

and female raters.

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using Choukroun’s platelet-rich

fibrin as grafting material: A 1-year

prospective pilot study with

microthreaded implants. Oral Surg

OralMed Oral Pathol Oral Radiol

Endod 2008;105:572- 579.


1326

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TABLES:

Group No Mean SD SE T P-value

Bone gain after 3

months

Gelfom 10 3.07 1.54 0.49 -4.117 *0.001

PRF 10 5.53 1.10 0.35

Bone gain

between 3 and 6

months

Gelfom 10 2.98 1.12 0.36 4.460 *0.000

PRF 10 1.03 0.80 0.25

Total bone gain

after 6 months

Gelfom 10 6.05 1.13 0.36 -0.909 0.375

PRF 10 6.55 1.36 0.43

Table 1: bone gain

*:P-value ˂0,01 which means there is significance difference between the two groups

Group No Mean SD SE T P-value

Bone density after

3 months

Gelfom 10 118.85 4.61 1.46 -5.065 **0.000

PRF 10 130.37 5.52 1.75

Bone density after

6 months

Gelfom 10 135.54 4.14 1.31 -5.432 **0.000

PRF 10 147.82 5.83 1.84

Table 2: bone density according to Digora software

**: P value ˂0.01 which means that there is significance difference between the two groups


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FIGURES:

Figure 1: preoperative panoramic x-ray

Figure 2: A: a buccal flap was created, B: outline the lateral bone window, C: sinus membrane

elevation, D: osteotomy was prepared for implant, E: implant was inserted, F: filling the new

compartment under the elevated sinus membrane with PRF clots.


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Figure 3: panoramic x-ray 8 days after surgery showing the residual alveolar bone height in

implant site measured by Digora software, since PRF is radiolucent.

Figure 4: panoramic x-ray 3 months after surgery demonstrating bone gain around implant intra

sinus measured using Digora software.

Figure 5: panoramic x-ray 6 months after surgery showing the new sinus floor approximately at

the level of implant tip.

Documents

COMPARISON BETWEEN PRF AND GELATIN SPONGE AS FILLING